MEDICAL RECORD REVIEW SUMMARY by CraigR

VIEWS: 0 PAGES: 9

									                                                                           Confidential QI Report
                                                                       San Diego County Mental Health Plan
                                                                         Children's Mental Health Services
                                                                                 Fiscal Year 05-06

                                                              MEDICAL RECORD REVIEW SUMMARY
    Provider Name:                                                                                                                 Provider No.

 Parent Organization:                                                                                           Reviewer:

            RU(s):
                                                     Crisis Intervention                   Medications                                AB2726
   Service Provided
                                        Case Management                       Day Intensive               Day Rehabilitation       Outpatient        Other

      Review Date:                                            Billing Audit Period:                  to

                                            No. Records Reviewed:                                         Overall Compliance

 Chart                                                             Progress               Administration                                            Utilization
                InSyst No.            Assessment Client Plan                    Medical                  Discharge      Billing     Day Program
  No.                                                               Notes                   & Legal                                                  Review




                           Methodology: Percentage represents number of yes response(s) divided by the total number of yes and no response(s).
                                                       Categoties are rounded up except for the Billing Category.
    Mean per Category:

 Require Plan of Correction:

Comments: Please refer to the comments section at the bottom of each category; they are intended to improve the quality of service and continue compliance.

Please note that:
         ► a Plan of Correction is required for any category that falls below a mean of 90%.
         ► 100% compliance is required in the Billing Category. A Plan of Correction is required if Billing Category compliance is not achieved.
         ► Plans of Correction are due to the QI Unit within 14 days of the date on the cover letter.




         HHSA-CMHS
         Medical Record Review Tool - Excel Rev. 9-22-05                                                                                                1
                                                                 Confidential QI Report
                                                             San Diego County Mental Health Plan
                                     Children's Organizational Provider Medical Record Review Tool
                                                                FY 05-06
           Record Review #                                   RU #                                         Provider #


                                Program Name                               Review Date                         Billing Audit Period
                                                                                                                           to
                Client Name                            Client InSyst No.             Client Insurance              Primary Therapist


                                               ASSESSMENT                                                                Yes      No
1. Initial assessment completed in entirety within 30 days of first planned visit
2. Annual assessment update is completed within required timelines
3. Mental health history is documented
4. Client’s ethnicity, primary language, and sociocultural history are documented
5. Youth Transition Self Evaluation completed within 30 days of intake or transfer (Starts at
   age 16, at least annually, and at 17 1/2)
6. Religious/spiritural issues that are important in the client's life are documented
7. Assets/strength identified by client are documented
8. Relevant physical health conditions reported by the client are identified
9. Client self-report of allergies and adverse reactions to medications, or lack of known
   allergies and/or sensitivities ares clearly documented and allergy stamp is present on
   front of medical record
10. Past and present use of alcohol, drugs and tobacco are documented when applicable
11. Current mental status examination is completed
12. A five axis diagnosis is consistent with the presenting problems, history, mental
    status examination, and other assessment data
13. A safety assessment that includes risks of harm to self or others is completed
14. Documentation indicates provision and explanation of beneficiary handbook, review of
    grievance/appeal process, and explanation of program’s services and rules at admission
    and annually (client informed of right to have Advance Directives when applicable)
15. Is signed by either a Physician, Psychologist (or waivered Psychologist
    candidate), LCSW, ASW, MFT, IMF, or RN (Trainee with co-signature)
16. If co-signature is required, the licensed/waiver/registered staff member has signed
     within 30 days of first planned visit
17. Client assessed to detect the presence of co-occurring substance use and evidence
    is documented
18. Diagnosis of co-occurring substance disorders are clearly documented in the chart
    when identified in the assessment
                                                                                                                 Total 0              0
                                                                                                        Percent Compliance:
Assessment Comments:




     HHSA-CMHS
     Medical Record Review Tool - Excel Rev. 9-22-05                                                                                      3
                                                               Confidential QI Report
                                                           San Diego County Mental Health Plan
                                   Children's Organizational Provider Medical Record Review Tool
                                                              FY 05-06
         Record Review #                                   RU #                                         Provider #


                              Program Name                               Review Date                         Billing Audit Period
                                                                                                                         to
              Client Name                            Client InSyst No.             Client Insurance              Primary Therapist




                                               CLIENT PLAN                                                             Yes      No
19. Completed within 30 days of the first planned visit
20. Signed by the client, parent/guardian or reason documented why not signed
21. Initial Client Plan is signed by either a Physician, Psychologist (or waivered
    Psychologist candidate), LCSW, ASW, MFT, IMF, or RN (Trainee with co-signature)
    within 30 days of first planned visit
22. Client Plan rewritten every 6 months or prior to UR
23. Subsequent Client Plans are signed or co-signed by a licensed/waivered/register staff
24. Client strengths and abilities to apply toward goal are documented
25. Client Plan has specific, observable, and quantifiable goals that are client focused (Goals
    correlate to IEP goals for AB2726 providers)
26. Identifies the proposed type(s) of intervention
27. Has proposed duration of intervention
28. Focus of intervention is consistent with presenting concerns, mental health history,
    and diagnosis
29. Intervention(s) identified is likely to lead to achievement of Client Plan goals
30. Client Plan includes either a goal/objective or indication of a referral when a co-occurring
    issue has been documented, when applicable
                                                                                                               Total 0              0
                                                                                                      Percent Compliance:
Client Plan Comments:




   HHSA-CMHS
   Medical Record Review Tool - Excel Rev. 9-22-05                                                                                      4
                                                               Confidential QI Report
                                                           San Diego County Mental Health Plan
                                   Children's Organizational Provider Medical Record Review Tool
                                                              FY 05-06
         Record Review #                                   RU #                                         Provider #


                              Program Name                               Review Date                         Billing Audit Period
                                                                                                                         to
              Client Name                            Client InSyst No.             Client Insurance              Primary Therapist


                                          PROGRESS NOTES                                                                Yes     No
31. Relate to treatment goals and objectives, documenting ongoing medical necessity
32. Document client encounters, including clinical decisions and interventions
33. Reflect continuity and coordination of care between primary therapist, consultants,
    ancillary providers, and/or primary physician, if applicable
34. Document use of community resources such as relapse prevention, stress
    management, and/or wellness programs, as indicated
35. Document measures taken to meet language needs of client and includes client’s
    response to offer of an interpreter, if applicable
36. Document client was seen by a mental health professional within 72 hours of
    discharge from an inpatient/crisis residential facility, if applicable
37. Documentation addresses co-occurring substance use issues if identified in Client Plan (specific
    to goal or transition/aftercare plan) while keeping the primary focus on the mental health
    diagnosis
                                                                                                               Total 0              0
                                                                                                      Percent Compliance:
Progress Notes Comments:




                                                MEDICAL                                                                 Yes     No
38. Child/Youth History Questionnaire (MHS-651) completed within 30 days according to
    specified timelines and signed by clinician
39. Informed Consent for the Use of Psychotropic Medications (MHS-005) signed and dated
    by physician and legal guardian or Ex Parte when applicable
40. Psychiatric/Medication Evaluation (MHS-645) completed when client is evaluated for meds
41. Medication Follow Up (MHS-689) is completed each time client is seen for medication f/u
42. If a co-occurring substance use disorder is documented, physician documentation demonstrates
    awareness of the disorder
                                                                                                                Total    0          0
                                                                                                      Percent Compliance:
Medical Comments:




   HHSA-CMHS
   Medical Record Review Tool - Excel Rev. 9-22-05                                                                                      5
                                                               Confidential QI Report
                                                           San Diego County Mental Health Plan
                                   Children's Organizational Provider Medical Record Review Tool
                                                              FY 05-06
         Record Review #                                   RU #                                         Provider #


                              Program Name                               Review Date                         Billing Audit Period
                                                                                                                         to
              Client Name                            Client InSyst No.             Client Insurance              Primary Therapist



              ADMINISTRATIVE/LEGAL - 43 to 45 for County of San Diego programs only                                    Yes      No
43. A Consent for Mental Health Services (MHS-272) has been signed by client and/or
    guardian or Ex Parte when applicable
44. Acknowledgement of Receipt (NPP-001) of the HIPAA-NPP is signed/dated by legal
    guardian or staff explanation with signature/date
45. Authorization to Use or Disclose Protected Health Information (23-07 HHSA) signed/dated
    by client or guardian and witnessed / or 04-24A (C or P) dated 06/2003
46. Medical record complies with format requirements and documentation guidelines
    as outlined in the Documentation and Uniform Clinical Record Manual
47. Medical record documentation uses only approved standardized medical abbreviations
                                                                                                               Total 0              0
                                                                                                      Percent Compliance:
Administrative/Legal Comments:




                                               DISCHARGE                                                               Yes      No
48. Discharge note completed for client seen 4 or fewer times
49. Discharge Summary (MHS-653) completed in entirety for clients seen 5 or more times,
    or if case converted to medication only
50. Completed by qualified staff (licensed, waivered, registered, or trainee with co-signature)
51. Discharge Summary is completed within 14 days of discharge
52. Discharge Summary documents assessment results, course of treatment, and
    response to treatment
53. Record documents client and parent/guardian involvement in discharge planning and
    aftercare plan
54. Documents aftercare plan
55. Planned discharge documents that referrals were made for substance use treatment when
    indicated
                                                                                                               Total 0              0
                                                                                                      Percent Compliance:
Discharge Comments:




   HHSA-CMHS
   Medical Record Review Tool - Excel Rev. 9-22-05                                                                                      6
                                                               Confidential QI Report
                                                           San Diego County Mental Health Plan
                                   Children's Organizational Provider Medical Record Review Tool
                                                              FY 05-06
         Record Review #                                   RU #                                         Provider #


                              Program Name                               Review Date                          Billing Audit Period
                                                                                                                          to
              Client Name                            Client InSyst No.             Client Insurance               Primary Therapist




                                                               BILLING
                                                                                                                        Yes      No
             100% Compliance required in this category- Plan of correction required for any deficient items
56. All entries include the legible signature of the person providing the services and the
    person’s professional degree, licensure, and/or job title
57. All entries include the date services were provided
58. All entries include the duration of the services
59. All entries include the location of the services
60. All entries are legible
61. All entries document appropriate CPT/HCPCS code for type of service provided
62. Client Plan is present, completed within required timelines, and document client's / legal
    guardian's involvement (see findings in Client Plan section of this tool)
63. Case consultation and Treatment Teams are documented accurately
64. All entries have required fields on form completed (CPT/HCPCS code, location code,
    DSM/ICD-9 code(s), date of documentation, etc.)
65. CPT/HCPCS code entered into InSyst corresponds to code used in documentation
66. An entry is present in the chart to correspond with each billing event
67. All entries have sufficient documentation to substantiate the duration of the services
    being billed
68. All time claimed is equal to time documented
69. All claimed services are billable according to Title 9 requirements (eg. Lockouts and non-
    billable activities)
70. At admission time, medical necessity is consistent with Title 9 requirements and
    documented accordingly
71. Progress Notes document on-going medical necessity consistent with Title 9
    requirements
72. Client 'no shows' have not been billed, or if billed, are documented appropriately with what
     treatment service was performed
73. Group Progress Note (MHS-924) has Group Formula properly documented
74. Claim for group billing has been properly apportioned
                                                                                                                Total     0          0
                                                                                                      Percent Compliance:
Billing Comments: (Refer to Next Page)




   HHSA-CMHS
   Medical Record Review Tool - Excel Rev. 9-22-05                                                                                       7
                                                               Confidential QI Report
                                                           San Diego County Mental Health Plan
                                   Children's Organizational Provider Medical Record Review Tool
                                                              FY 05-06
         Record Review #                                   RU #                                              Provider #


                              Program Name                                 Review Date                             Billing Audit Period
                                                                                                                               to
              Client Name                            Client InSyst No.               Client Insurance                  Primary Therapist


                                                                         BILLING
                             100% Compliance required in this category- Plan of correction required for any deficient items
Billing Comments:




   HHSA-CMHS
   Medical Record Review Tool - Excel Rev. 9-22-05                                                                                         8
                                                                  Confidential QI Report
                                                              San Diego County Mental Health Plan
                                      Children's Organizational Provider Medical Record Review Tool
                                                                 FY 05-06
            Record Review #                                   RU #                                         Provider #


                                 Program Name                               Review Date                         Billing Audit Period
                                                                                                                            to
                 Client Name                            Client InSyst No.             Client Insurance              Primary Therapist



                                               DAY TREATMENT / DAY REHABILITATION                                          Yes     No
75.      Daily notes that describe the service provided are documented for Day Treatment
         Intensive
76. Weekly summary notes include dates of each day attended (with services provided)
    for Day Treatment Intensive and Day Rehabilitation
77. Weekly summary notes reflect progress toward goals, interventions, and responses for Day
Intensive and Day Rehabilitation
78. Document a minimum of one contact a month with family and/or significant support
     person
79. Documentation on appropriate form of at least one psychotherapy contact per week for
     Day Treatment Intensive
80. Monthly summaries are in record for Day Treatment Intensive
81. Quarterly Reports are in record for Day Treatment Intensive
    (For AB2726 only clients, quarterly request for authorization are acceptable)
82. Authorization request(s) are completed for services billed
                                                                                                                   Total    0          0
                                                                                                         Percent Compliance:
Day Treatment / Day Rehabilitation Comments:




                                                         UTILIZATION REVIEW                                                Yes     No
83. Utilization Review authorization in place that covers dates of services reviewed
84. UR committee comprised of licensed or waivered staff
85. An authorization for ancillary services is present when applicable
86. A face sheet (MHS-140 or 141) is present in the record
                                                                                                                   Total    0          0
                                                                                                         Percent Compliance:
Utilization Review Comments:




      HHSA-CMHS
      Medical Record Review Tool - Excel Rev. 9-22-05                                                                                      9
                                                               Confidential QI Report
                                                           San Diego County Mental Health Plan
                                   Children's Organizational Provider Medical Record Review Tool
                                                              FY 05-06
         Record Review #                                   RU #                                         Provider #


                              Program Name                               Review Date                         Billing Audit Period
                                                                                                                         to
              Client Name                            Client InSyst No.             Client Insurance              Primary Therapist


                                                        ADDITIONAL ITEMS                                                Yes     No
87. CAMS and Assessment Summary present in the Medical Record (intake, 6 month intervals,
discharge)

88. CAMS and Assessment Summary findings consistent with Client Plan goal(s) and Progress Notes
                                                                                                                Total    0          0
                                                                                                      Percent Compliance:
Additional Items Comments:




   HHSA-CMHS
   Medical Record Review Tool - Excel Rev. 9-22-05                                                                                      10

								
To top